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A NEW METHOD 







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TREATING STRICTURES 






OF THE 



URETHRA, 



AFTER 



I ^EXTERNAL SECTIONS. 

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BY C. H. MASTIN, M. D., 

mobile, ala. 



': 'READ BY REQUEST BEFORE THE MOBILE PATHOLOGICAL 

S< )i 'IETY, SEPT. 9th, 1872. 






LOUISVILLE, KY. : 

MEDICAL JOURNAL PRINT. 
1873. 



TNI 

ABNER WELLBORN CALHOUN 

MEDICAL LIBRARY 

1923 



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PRESENTED BY 



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A NEW METHOD 

OF 

TREATING STRICTURES 

OF THE 

URETHRA, 

AFTER 

EXTERNAL SECTIONS. 

BY C. H. MASTIN, M. D., 

MOBILE, ALA. 
[Head by Request before the Mobile Pathological Society.] 



Gentlemen, — It is not my intention to consume your time 
with a didactic article upon Urethral Stricture, I only propose 
to call the attention of the Society to a modification of an 
operation, which, in my hands, has afforded unusual results; 
and, by comparison with other methods, to try and point out 
certain ottier advantages which I believe its adoption will fur- 
nish. 

This article is written especially as a prelude to a report of 
cases ; cases which many of you have seen, and which will be 
given to illustrate the proceeding which I have adopted; a pro- 
ceeding which shall be recorded with an accurate truthfulness 
as to results. As yet I do not claim this method to^be perfect, 
or that we will in all cases meet with invariable success. 



2 

Much has been done, but still more remains to be accomplished 
before the method will be fully established. Yet I do not 
hesitate to say, from the success which has crowned my efforts, 
that I believe the end of further experience will be, that a 
hitherto serious and dangerous operation will be robbed of 
its terror by the adoption of the method, as I shall describe it. 

From the remotest times surgeons have been compelled to 
resort to external incisions in particular cases of severe and 
unmanageable strictures of the urethra, when ordinary meas- 
ures had failed to afford relief. 

The operation which is generally known as "The External 
Section" or "External Urethrotomy," has within a few years 
past been popularized by a surgeon of Edinburgh (who is dis- 
tinguished especially in this department of surgery), and has 
found its w T ay into general practice as the " Perineal Section " 
or "External Urethrotomy" of Mr. Syme. 

Indeed, it would appear that it is only of late this proceed- 
ing has been known to the Profession at large, although when 
we come to investigate the subject, it is apparent that it is by 
no means a new operation, but one of considerable antiquity, 
and before we enter into the merits of the same, it may serve a 
purpose to examine and see to what extent the old writers were 
acquainted with this operation. 

They knew and wrote of an operation which they called "La 
Boutonniere." It is unfortunate, as suggested by Dr. Gouley, 
of New York, that there has been so much uncertainty in the 
exact definition given of the various methods of performing 
this operation. The term "boutonniere" is an undefined ^term, 
it means one thing here and another thing there, it is applica- 
ble to operations at any point in the urethra, whilst the term 
" Perineal Section " would refer alone to those incisions made 
in the perineum. So also " Perineal Urethrotomy" of Giviale is 
alike applicable to either internal or external urethrotomy done 
in the perineal region. 

The " External Urethrotomy " of Syme is indefinite, it refers 
to an external operation done in any part of the canal. Prob- 



ably the most unexceptionable term is the one proposed by Dr. 
Gouley — viz., "External Perineal Urethrotomy," and none 
other could be preferable where the operation is performed " in 
perineo "j but as external sections may be called for in the en- 
tire course of the canal, it seems to me that by designating the 
point at which the operation is done, a clearer understanding 
would be given. As there are three distinct regions* in which 
strictures are to be found, I have thought it would render the 
description more explicit by using the term " External Ure- 
throtomy in the first, second, or third region," as the case may 
be. Thus, when an operation is done in perineo, we would 
say, " External Urethrotomy in the first region " ; when anterior 
to the scrotum, "External UrethrQtomy in the second or third 
region" according to the exact locality. 

It appears to me this classification simplifies the description, 
and that a clearer understanding can be given by its adop- 
tion. 

The distinguished Wiseman, a surgeon of more than ordinary 
ability in the early part of the seventeenth century, was cer- 
tainly acquainted with the operation of opening the urethra in 
cases of retention of urine dependent upon impermeable stric- 
tures, and this fact is clearly proved by a case which he narrates 
in his Surgeryf as having occurred under his observation in the 
practice of Mr. Edward Molins. 

" An old fornicator having been long diseased with a carnos- 
ity, which had resisted all endeavors, and in a manner totally 

* The First Region is at the sub-pubic curvature, or that portion of the canal 
immediately in the vicinity of the junction of the spongy, with the mem- 
branous parts, being 1 inch in front of and f of an inch behind the junction, 
thus including the entire membranous portion with one inch in front, which 
gives the first region a length of If inches. 

Tee Second Region extends from the anterior limit of the first region to 
within 2£ inches of the external meatus of the urethra, consequently being in 
length from 21 to 3 inches. 

The Third Region is from the anterior extremity of the second to the me- 
atus externus, being a space of 2J inches, and embracing the fossa navicularis. 

f See Wiseman's Surgery, p. 76. The author on " Internal Urethrotomy." 



suppressed his urine, sent for him. He went and caused the 
patient to be taken out of bed and placed upon a table with his 
legs drawn* up as in cutting for stone. He cut into the urethra 
near the neck of the bladder; it was as hard as a gristle. His 
knife did not readily divide it; but so soon as he had, the urine 
gushed out, which being discharged, he put his finger into the 
urethra, and afterwards enlarged the incision upwards more to 
the scrotum, then dressed it with his green balsam warm, by 
which in a few days it digested, and the patient was relieved; 
the lips grew also daily shorter, and the wound healed apace. 
But all this while the urine had no other passage, the common 
ductus being so closed up, by reason of the carnosity, that we 
could not make any way into it with our smallest probes or 
candles, upon which consideration it was thought necessary to 
keep the opening in perineo for the discharge of the urine, and 
in order thereto it was dressed with a dossil, an emplaster, and 
compress, which the patient took off at times to ease nature. 
But this not satisfying him, he frequently complained' of his 
unhappy condition, in so much that Mr. Edward Molins, being 
wearied with the patient's solicitation, took me one morning 
along with him, when again he placed the patient as before, and 
attempted to make a way from the apex into the urethra; but 
it was in vain ; whereupon he caused one of his servants to hold 
the one leg and myself the other, while he took up the testicles 
and put the one into my hand, and the other he placed into the 
hand of his servant ; then with his knife divided the scrotum 
in the middle (we holding each testicle the while in our hands) 
and cutting into the urethra, slit it the whole length of the in- 
cision in perineo; then with a needle and thread stitched the 
skin over the urethra, as also the scrotum, leaving the testicles 
covered as before, and dressed them with agglutinatives, by 
which they were cured in a few days, but the urine neverthe- 
less continued to flow by the opening in perineo." 

There can be no question that this was a case of obstinate 
stricture of the urethra, and that Mr. Molins had to resort to the 
operation of " External Urethrotomy in the first region," which, 



however, resulted in a perineal fistula; here no guide was passed 
through the stricture, and his first operation was doubtless per- 
formed behind the stricture for the purpose of giving exit to 
the retained urine. The second operation at which Wiseman 
assisted was done in front of the stricture, and upon the prin- 
ciple of la boutonniere. Subsequently to this operation, Wise- 
man himself performed an operation for the same cause, and 
after the same method, but, as it appears, with no better suc- 
cess, for " a fistula remained in the perineum." 

In 1730, A. D., over one hundred years before Mr. Syme per- 
formed his first operation, which was in 1844, Le Dran oper- 
ated by this method upon a case of "organic impassable stric- 
ture," which operation he performed at two sittings ; at the first 
he opened the perineum down to the urethra, on the next day 
he opened the urethra, and in the course of five days having 
gradually introduced a bougie on into the bladder, he "slit up 
the urethra behind the stricture as far as the neck of the blad- 
der," doing, as he says, " the same incision as for the stone, and 
taking care to avoid the rectum." After which he gradually 
dilated the canal with sounds, and the patient got well. 

Sometime anterior to this, Francois CoHpt, the distinguished 
French lithotomist, relates the history of two cases of obstinate 
stricture, complicated with numerous fistulce, upon which he had 
operated by external incision in 1690, A. D. } both of which he 
reports as being cured. 

Even before this date F. Tolet, in his writings, speaks of the 
operation of " la boutonniere." 

Still later, we find John Hunter, in his great work " On Ve- 
nereal," London, 1788, advising this operation for the cure of 
strictures complicated with perineal fistulte, he himself having 
performed the operation for this purpose in 1783, at St. George's 
Hospital, in London, and in his description of the proceeding, 
thus writes : 

"This must be done by an operation which consists by 
making an opening into the urethra somewhere beyond the 
stricture, and the nearer the stricture the better. The method 



6 

of performing the operation is first to pass a director or some 
such instrument into the urethra as far as the stricture; then 
to make the end of the instrument as prominent externally as 
possible, so as to be felt, which, in such a case, is often difficult, 
and sometimes impossible. If it can be felt, it must be cut 
upon, and the incision carried on a little further toward the 
.bladder or anus, so as to open the urethra beyond the stricture. 
This will be sufficient to allow the urine to escape and to de- 
stroy the stricture. If the instrument cannot be felt at first 
by the finger, we must cut down towards it, which will bring it 
within the feel of the finger, and afterwards proceed as above 
directed."* 

Another very clear and positive description of an external 
section for the relief of an obstinate stricture. 

Again, Mr. Sharp, in his essay entitled "A Critical Inquiry," 
published in London, 1750, describes this operation "by cutting 
in perineo if possible upon a staff." 

Then we find Chopart performing the operation " la bouton- 
niere in 1786" upon a case of stricture which was complicated 
with fistulse, the fistules healed, but the wound in the perineum 
refusing to do so, the urine all passed in that way. 

Still searching the literature of England, we find Sir Charles 
Bell, speaking of this operation for the cure of strictures which 
are complicated with fistulas in the perineum, describing it in 
the following language : 

"This state of the parts requires a different operation, one ill to 
suffer and requiring dexterity and niceness in the operator. The 
patient is placed in the position of lithotomy; a straight cathe- 
ter or sound is introduced into the urethra down to the ob- 
struction, then a probe is introduced into the fistulous opening 
in the perineum ; often the straight probe will not follow the 
obliquities of the canal; it must be bent, and made if possible 
to hit upon the extremity of the catheter or sound. It 
cannot be made to touch the catheter, because the catheter 

* " Hunter on the Venereal." London, 17S8, p. 209. 



is within the urethra and above the stricture. The di id 
integuments of the perineum are now to be hud open down 

to the tract of the urethra. If there is one sinus leading 
towards the stricture, it is to be followed; but if there an 
eral, and they run deep backwards, it is impossible to follow 
them towards the neck of the bladder. In this part of the 
operation a decided incision and a fair wound is to be v, : 
for."* 

In continuance of this description he goes on to state — ■ 

" If we should fail in attempting to introduce the probe into 
the fistulous communication, we must cut upon the stricture and 
the point of the staff; and noiu again searching with the probe 
for the continuation of the canal towards the bladder, and hav- 
ing found it, introduce the catheter from the point of the penis 
past the stricture down into the bladdery 

There could not possibly be written a sentence which would 
more clearly describe an operation than does this one, " the 
External Section," which is known and described by the French 
writers as "la boutonniere "; yet it is a very difficult matter to 
arrive at the exact idea which these authors wish to convey 
when they use this term. The operation has been performed in 
so many w T ays that we are at a loss to understand the precise 
operative procedure which different writers wish to class under 
the general term. The locality at which the operation is done 
necessitates a change in the line of incision ; in one instance the 
urethra is opened at a point just above the stricture ; in an- 
other, the knife penetrates even to the neck of the bladder; 
whilst' in the next, the neck and body of the prostate are 
opened as in the lateral operation for stone. 

The most explicit description of this operation is to be found 
in the works of P. J. Desault, edited by Xavier Bichat. In his 
treatise upon the Urinary Organsf we find the following lan- 
guage, which explains the operation and shows it to be almost 

* Sir Charles Bell, " Operative Surgery." London, 1807, p. 121. 

f Desault, Traite des maladies des voies urinaires, p. 330. Tome III., Paris, 
1830. 



identical with that of Mr. Syme. "On ne suit pas toujours le 
meme procede en pratiquant la boutonniere sur le canal de 
l'uretere. Lorsque Ton peut introduire un catheter dans la ves- 
sie, on se sert de cet instrument pour faire sur sa cannelure 
Tincision du canal et conduire une gorgeret. Ici l'operation ne 
presente pas plus de difficulte ni de danger que l'incision pour 
la taille au grand appareil, mais aussi elle n'offre aucun advan- 
tage dans le traitement des retentions d'urine ; car puisque on a 
\j pu introduire un catheter, il eut/servi a levacuation de l'urino 
et r6tabli par son sejour la liberte du canal." 

This evidently shows the operation was done by passing 
down a grooved director to the anterior face of the stricture, 
and also by passing the instrument through the coarctation it- 
self, after which the stricture was cut upon the director. It 
has been asserted that this operation was done by Desault, not 
for the cure of stricture, but for the relief of retention of urine. 
If done for the relief of retention, it was certainly a most un- 
called for proceeding, for we see that he passed the sound through 
the stricture, and upon the same principle that Mr. Syme p >ts 
out — viz., where the urine can pass, through the same opening 
he can pass a director. Now vice versa, wherever a sound can 
be made to pass, there also is an opening for the discharge of 
the urine. That such however was not the idea which Desault 
wished to convey, we have but to turn to the same work above 
quoted, and read upon page 245, where he is treating of stric- 
ture and its cure, not of retention, as follows : 

"L'operation connu sous le nom de l'boutonniere, quoique en 
apperance mieux adaptee a la nature de la maladie, est presqw 
toujours ou inutile ou dangereuse. Elle est inutile, si pour la 
pratiquer on peut passer un catheter ou une sounde cannulSe ; 
puisque alora on aurait pu de mime y porter une sound* 
creuse; elle est dangereuse si Ton ne peutetre guide par ces in- 
struments; puisque alors on fait les incisions au hazard, et que 
Ton peut manquer le canal, et divisor des partes dont la lesion 
est Buivie i mta plus on moins grave." 

Without taxing the reader with a more extended histoi 



9 

notice of the operation, it will be well to analyze the same, and 
see what deductions can be drawn from the descriptions which 
are given by various writers. It is very clear to my mind that 
la boutonniere was performed in three ways. The first method 
is the one especially noted by Desault, and is essentially the 
same in every respect as the operation of Mr. Syme — viz., upon 
a conducting director, which is passed through the stricture, 
and upon which the incision is made. Secondly, where a staff 
is passed down to the anterior face of the stricture and the 
urethia opened in front, then the stricture, together with the 
integuments all laid open upon a director, which is introduced 
through the stricture from its distal opening. Thirdly, in 
which a staff is passed down to the stricture, and the urethra 
opened in the membranous portion posterior to the obstruction, 
through which opening a grooved probe is introduced past the 
stricture until it comes in contact, or nearly so, with the end of 
the staff, which lies upon the anterior face of the coarctation, 
in the groove of which a knife is passed from behind forwards, 
and tlr entire stricture, wall of urethra, integuments and all, 
ripped open. This latter is the method generally adopted by 
the French surgeons. It appears to me that there will be 
much difficulty in opening the urethra, unless there is a staff 
present against which the point of the knife can be directed, 
and unless the opening in the membranous urethra can be made 
surely and smoothly, we run the risk of urinal infiltration with 
all its concomitant results. 

W« now propose to notice and describe the operation of Mr. 
Syme' a method which in recent years has been much in vogue, 
and which has caused much angry discussion. It is not my in- 
tention to reflect any thing upon his operation or to pretend to 
decide whether it was original with himself, or borrowed from 
the older sugeons. A brief review of the history of the opera- 
tion will decide the question as to whether it was a creation of 
this distinguished Edinburgh Professor or a revival of a pro- 
ceeding whicii had fallen into disuse. For our purposes, it will 
suffice to quote Mr. Syme's own description of his operation, 



10 

and leave it to be compared with that of the other writers 
already referred to ; more especially with the description given 
by Bichat of the operation performed by Desault. Of course, 
Mr. Syme presumes the patient to be placed under the influ- 
ence of some anaesthetic, and secured in the position of lithot- 
omy, when he writes — 

" He is brought to the edge of the bed, and his limbs sup- 
ported by two assistants, one on each side, a grooved director, 
slightly curved and small enough to pass readily through the 
stricture, is next introduced, and confided to the care of an 
assistant. The surgeon sitting or kneeling on one knee, now 
makes an incision in the middle line of the perineum or penis, 
wherever the stricture is seated; it should bean inch or an 
inch and a half in length, and extend through the integuments 
together with the subjacent textures exterior to the urethra. 
The operator now takes the handle of the director in his left 
hand, and a small, straight bistouri in his right, feels with his 
fore finger guarding the blade for the director, and pushes the 
point into the groove behind, or on the bladder side of the stric- 
ture, runs the knife forwards, so as to divide the ivhole of the thick- 
ened texture at ihe contracted part of the canal, and withdraws 
the director ";* a silver catheter is then introduced along the 
urethra into the bladder, and bound in by tapes passed through 
the rings of the catheter and tied around the loins ; it is left in 
from forty-eight hours to four days, after which time it is re- 
moved, and at the expiration of eight or ten days a bougie is 
to be passed, and its introduction repeated every eight or ten 
days for two months. 

It will be observed that Mr. Syme makes a point, that the 
stricture should be permeable, for he distinctly says in his work 
on stricture — 

" Now, there is nothing of more consequence in the treat- 
ment of strictures than the knowledge of the fact that this 
alleged impermeability has no real existence, except in those 

* Syme on Stricture of the Urethra, Edinburg, 1852. 



11 

rare and exceptional cases, where the urethra has been divided 
by violence, and allowed to cicatrize with obliteration of the 
passage beyond the opening at the seat of injury. It is obvi- 
ous indeed that if the urine is permitted to pass, no matter 
how small a stream, or even by drops, there must be room for 
the introduction of the instrument if it be sufficiently small 
and properly guided." 

Still with this passage, fresh from the pen of Mr. Syme, 
staring us in the face, we find him on two occasions dealing 
with strictures where he found it impossible to pass a director, 
although " sufficiently small and properly guided," he icas un- 
able to effect an entrance, and was forced to perform la bouton- 
niere (in our second classification), that is, by opening the 
urethra at the seat of the stricture and passing a grooved 
probe from the distal face toward the bladder. 

I am forced to look upon the operation of Mr. Syme as one 
against which grave objections can be brought to bear. He 
starts out with the broad proposition: "No stricture is imper- 
meable " (excepting of course those cases where the urethra has 
been injured and the canal opened, a fiV.ule remaining, with the 
tube anterior united in its walls at the site of injury) "that 
wherever a drop of urine can pass, with care and patience an 
instrument can be introduced." This may answer very well in 
those simple cases of linear stricture, which are little more 
than a thread around the urethra, being of no extent antero-pos- 
teriorly. Here the mere entrance of an instrument into the 
orifice of the stricture is almost equal to its passage, the least 
pressure will effect all which is required ; but in those cases of 
long, tortuous stricture, where there is an extensive fusion or 
blending together of the rug» of the urethra, complicated 
perhaps with more than one false route, it will require the 
utmost dexterity to introduce an instrument; such dexterity 
and manipulation as does not belong to many men; it may be 
possible for the gifted surgeon of Scotland to effect this much, 
but for those who are not in constant practice, with a daily and 
almost hourly use of urethral instruments, those practitioners 



12 

of medicine who are scattered through the towns, villages and 
rural districts of our country, who do not handle a sound or 
catheter once in a twelve month, but who may be called upon 
at any time to perform such an operation, in cases of emerg- 
ency, they will, in ninety-nine out of every hundred cases, fail 
to effect an entrance. 

If, however, the assertion of Mr. Syme is correct, that no 
stricture is impermeable, then I cannot see the necessity or pro- 
priety of resorting to so dangerous and difficult an operation as 
" External Urethrotomy " to effect a cure, for wherever a guide 
rod to a sound can be passed through a stricture, there also can 
the conducting rod or bougie of the Internal Urethrotome be in- 
troduced, and I am sure no sane man, or one who values the 
life and happiness of his patient, with all the dangers and diffi- 
culties of an external operation clear before his mind, could 
prefer such a proceeding to the more delicate and less danger- 
ous operation of internal section, performed with' the urethro- 
tome of Maissoneuve, Trelat, Eicord, or the more ingenious 
one, recently devised and fabricated by that accomplished cut- 
ler of Paris, M. Mathieu. 

If circumstances should make it necessary that we should 
perform the operation of external urethrotomy, it is clear to 
my mind, with all the lights before me, la boutonniere is, par 
excellence, the one most deserving of selection. I mean la bou- 
tonniere as it is described in my second classification, that is 
upon the point of a staff. Here we are in front of the stric- 
ture, and can limit our incisions from before backwards, whilst 
in the operation of Mr. Syme, or la boutonniere in the first de- 
gree, we open the urethra posterior to the stricture, and where 
the same is located in the first region, Ave run the risk of cut- 
ting the deep perineal fascia, with the consequent danger of 
urinal infiltration of the pelvis and deep perineal region. With 
these points of objection clear before us, it seems strange in- 
deed that Mr. Symo himself should object to the la boutonniere, 
and that he should reject the operation as one "extremely 
hazardous and dangerous," and that too in cases where it ap- 



peara to be the only remedy. Yet he insists upon his own as 
one " free from danger," and that in cases of less gravity, where 
it is apparent his operation is the very same, with only a slight 
modification. It is not then astonishing that this operation of 
Mr. Syme should have met with so much opposition, and that 
too in his own country, notwithstanding his high (and deserv- 
edly so) reputation as one of the most distinguished surgeons 
of the British Isles; but it is a notorious fact, that even in his 
own city the most bitter invectives have been cast upon his 
operation, together with the serious charge that his cases have 
not been fairly or even correctly reported by himself. These 
charges have been made by some of the most distinguished 
members of the Colleges of Surgeons of England, Scotland, and 
Ireland. On the continent of Europe it has met with the same 
fate, and was even rejected by a Commission of the French 
Acaden^r, which sat in judgment upon it. It is said that Civ- 
iale himself never employed it, although he is known frequently 
to have resorted to the operation la boutonniere ; and in this 
country I believe it has not met with general favor. Dr. Gross, 
in his work on the "Urinary Organs,' thinks that all or nearly 
all strictures, which are not absolutely impermeable to urine, 
or those which are located in the membranous portion, or com- 
plicated with fistules of the perineum — false passages— with 
great and extensive induration of the adjacent tissues, admit of 
permanent, and in most instances, of prompt cure by dilatation 
either alone or aided by internal incision. 

In indulging in this opposition to the operation of Mr. 
Syme, I do not do so for the purpose of holding up la bouton- 
niere, or any of its modifications, as free from danger. Such 
are not the views which I entertain, nor the ideas which I wish 
to inculcate. Indeed, I do not know r of any operation done 
upon the genito-urinary system of like gravity, or more fraught 
with danger than this, and I concur fully in the opinion of De- 
fault, whose language is so well expressed at page 245 of his 
work, which I have before quoted. 

"Elle est dangereuse, si Ton ne peutetre guide par ces in- 



14 

struments; puisque alors on fait les incisions an hazard et que 
Ton peat manquer le canal, et deviser des parties dont la lesion 
est suive d'accidents plus au moins graves." 

Pi f. Samuel D. Gross, of Philadelphia, who is probably the 
best authority on genito-urinary surgery on this side of the 
great waters, and who would (as he does) stand deservedly high 
in any country or among any class of surgeons, is emphatic on 
this point, when he says, speaking of external sections as a 
class. 

" The operation is by no means free from danger, and re- 
quires the most consummate skill for its successful execution ; 
none but a madman or a fool would attempt it, unless he had 
the most profound knowledge of the anatomy of the parts, and 
a thorough acquaintance with the use of instruments. Of all 
the operations of surgery, this is the least to be coveted."* 

Still, as I have before remarked, there are cases wherein we 
are called upon to relieve the patient from retention of urine, 
caused by obstinate and impassable or impermeable strictures. 
Now, what are the indications which call for such an operation? 
what grave complications come up which demand such a pro- 
cedure? They are retention of urine, dependent upon a hard, 
firm organic stricture, through which no instrument can be 
made to pass, and which, if not relieved by some operation, 
either section of the strictured canal or puncture of the blad- 
der, must result in rupture of the urethra either anterior or 
posterior to the deep perineal fascia. Here we must either tap 
the bladder through the rectum, above the pubis, or by the 
perineum, or relieve the distension by the method of "aspira- 
tion," recently proposed and executed by M. Dieulafoy, of Paris; 
but as iiiJ of these methods admit of grave and serious objec- 
tions, as a consequence we must resort to the more rational 
operation of an external section, by which we hope to relieve 
not only the retention, but by the same operation cure the 
stricture, the cause thereof. 

, a 

" x " Gross on the Urinary Organs, p. 801, Philadelphia, 1855. 



15 

Under this class of causes we are to include cystitis, hyper- 
trophy of the walls of the bladder, dilatation? of the ureters, 
disorganization of the structure of the kidney, ursemic atura- 

tion, etc ., ing each of which such urgent constitu: 

distress. may occur that it will be dangerous to temporize in 

attempting relief by gradual dilatation of the stricture; and 
being unable to pass a conducting director through the coarc- 
tation, we are unable to do the operation of internal urethrot- 
omy, hence as a dernier, yet rational resort, we must perform 
an external section. But it must be remembered, these condi- 
tions are of comparatively rare occurrence; by far the great 
majority of strictures will admit of other means being em- 
ployed for their relief. In my own experience, out of a very 
large number of strictures which have fallen into my hands, 
the large majority have been treated by gradual dilatation, and 
successfully so. In about a hundred cases I have been induced 
to resort to internal urethrotomy, and in nine cases only have I 
found "external urethrotomy" requisite. 

But, should that rare contingency arise, should your milder 
measures utterly fail, should the urethra remain absolutely im- 
pervious — letting in no catheter, letting out no urine — then un- 
doubtedly, as I have stated, this condition would establish a 
necessity — a legitimate and imperative and urgent necessity — 
for your making an artificial vent for the contents of the dis- 
tended bladder.* 

Another condition is, where the urethra has given way, be- 
hind the seat of a stricture, and the urine at every contraction 
of the bladder is infiltrating the tissues, exciting them to in- 
.flammation and gangrene; here we are called upon to make 
large, free and open incisions, to evacuate effused urine; it is 
well in these cases to carry the knife freely through the stric- 
tured part, and thus open the canal to the passage of urine, as 
it may come from the bladder, thus insuring a cessation of in- 
creased infiltration, and, by a judicious operation, lay the 

* John Simon, F. E. S., " Clinical Lecture," St. Thomas's Hospital, London, 
1852. 



16 

foundation for a permanent and successful cure of the stricture. 

But it is pot ray intention to write a treatise upon stricture, 
or to detail the various causes or modes of treatment ; the na- 
ture of this article is simply to draw a comparision between the 
different methods proposed and executed in the form of external 
operations ; the digressions from the path laid out was necessi- 
tated to show the complications which arise in the course of 
this disease, and which demand such a proceeding for their 
relief. 

In this connection, it gives me pleasure, and, indeed, this 
paper would not be complete, unless I were to mention the very 
ingenious operation of Professor Gouley, of New York; an 
operation which I am pleased to consider as a very decided im* 
provement upon that of Mr. Syme, and one which reflects great 
credit upon th New York professor. I trust it will not be un- 
acceptable for me to give a description of the proceeding in Dr. 
Gouley 's own language, as taken from the " New York Journal" 
of August, 1869 : " The perineum having been shaved, the pa- 
tient is etherized-, the urethra is explored with a flexible bulb- 
ous bougie of proper size, to ascertain the exact seat of the 
obstruction. The canal is then filled with olive oil, and the 
capillary probe-pointed whalebone bougie is introduced into the 
urethra. If its point becomes engaged in a lacuna, it is with- 
drawn a little, and again carried onward with a rotary move- 
ment. If it enters a false passage, it is retained in situ by the 
left hand, while another is passed by its side. If this second 
probe makes its way into the false passage, it is treated pre- 
cisely as was the first, and the operation repeated till one guide 
can be made to pass the obstruction and enter the bladder. 
Sometimes five or six guides are thus caught before the false 
passage is filled up and the natural route opened. I have fre- 
quently succeeded in thus reaching the bladder in very narrow 
strictures, supposed to have been impassable, and after all other 
means had failed. As soon as a guide enters the bladder — 
which may be known by the ease with which an instrument 
may be moved in and out— the other guides are withdrawn. 



17 

The next step is to introduce a No. 8 grooved metallic catheter, 
with a quarter of an inch of its extremity bridged over, 20 as 
to convert the groove into a canal, the bridged portion itself 
being also grooved. Its introduction is accomplished by pass- 
ing through the canal the free end of the retained guide, then 
holding the latter steadily between the thumb and index finger 
of the left hand, and pushing the catheter-staff gently into the 
urethra, until its point comes in contact with the face of the 
stricture. The staff and guide are then kept in position by an 
assistant, who, at the same time, supports the scrotum. The 
patient is placed in the lithotomy position, and held by two as- 
sistants ; or better, by the aid of Prichard's anklets and wrist- 
lets. 

" The surgeon, seated on a low chair, first makes a digital 
exploration per rectum, to ascertain, as far as practicable, the 
condition of the membranous and prostatic divisions of the ure- 
thra ; he then makes a free incision in the median line of the 
perineum, extending from the base of the scrotum to within 
half an inch of the margin of the anus, involving only the skin 
and superficial fascia. The external incision, usually recom- 
mended in this operation, is from one inch to one inch and a 
half in length ; but I believe that free external incisions here, 
as in lithotomy, are of decided advantage, as they expose fairly 
to view the subjacent parts, and tend to prevent subsequent in- 
filtration of urine in the superficial layers. A few well-directed 
cuts having brought into view the urethra, the operator, with 
his finger nail, feels for the groove in the bridged portion of 
the staff, and opens the canal upon this groove, longitudinally, 
in the median line, exposing to sight the instrument. A loop 
of silk is then passed through each edge of the incised urethra, 
close to the face of the stricture, and held by the assistant in 
charge of the corresponding limb. This excellent contrivance, 
suggested and employed many years ago by Mr. Avery, of 
Charing Cross Hospital, London, is of great service, and ought 
not to be omitted, as it constantly keeps in view the median 
line. When the urethra is opened, and the loops are secured, 
2 



18 

the catheter is withdrawn a little, so as to bring into view the 
black guide ; then the stricture, with about half 'an inch of the 
uncontracted canal behind it, is divided. This, I think, is best 
accomplished by means of the small knife, which I have modi- 
fied from Weber's instrument for slitting the canaliculus laehry- 
malis. It is a very narrow, beaked, straight bistoury, about the 
size of a small probe, and is made to enter the stricture along- 
side of the guide, as if it were a probe, and the incision is done 
by directing the edge downward. The last step is to pass the 
catheter-staff, guided by the whalebone bougie, into the blad- 
der ; but should it be arrested in its course, the knife must be 
reintroduced and the incision extended further back. The ope- 
ration is thus completed without unnecessary delay, and the 
bladder is entered with the greatest gentleness ; and, by the 
free flow of urine through the catheter, the surgeon is certain 
that the instrument has gone in the right direction, that he has 
divided the stricture thoroughly, and that he has not simply 
enlarged a false passage." 

The after-treatment consists in confining the patient to a re- 
cumbent posture, with orders to take a hot hip-bath every night ; 
diluent drinks freely, with ten drops of the tincture of iron 
three times daily, and five grains of quinine at bedtime, with a 
suppository containing one grain of ext. opii. and half a grain 
of ext. belladonna every night to induce sleep. 

Immediately after the operation, ten grains of quinine with a 
quarter of a grain of morphia are administered. These are the 
outlines of the after-treatment. Dr. Gouley does not approve 
of tying in a catheter, but leaves the case to nature, and the 
urethra to the free passage of urine ; the wound is left to gran- 
ulate, as after lithotomy operations, and no sound is passed into 
the bladder until the second day. At the expiration of which a 
conical steel sound is passed, and its introduction repeated every 
third day until the wound is healed, which takes place in about 
four weeks. After which the patient is instructed in the use of 
an instrument, and advised to continue it indefinitely. Such, 
in as condensed a manner as possible, is the operation of Dr. 



19 

Gouley, and a most valuable contribution it is to the genito- 
urinary surgery of the present day. The only objection which 
I can find to his method, is the length of time required (as in 
all these operations) for the closing of the wound, which is an 
unavoidable consequence, where the wound is left to heal by 
granulation. As to the special views in reference to treatment 
after the operation, and preparation before, they are sustained 
by sound therapeutic principles. 

In closing this historical notice of the operation now under 
consideration, I desire to draw attention to the method of 
Henry Dick, of London, which he has brought before the Pro- 
fession under the term " Subcutaneous Division of Stricture." 
His method consists in first dilating the stricture sufficiently 
large to admit the director of his catheter ; which is a good 
sized silver catheter of moderate curve, upon the end of which 
are two buttons or knobs, with a groove between them ; the 
catheter being hollow, contains a small grooved directing rod, 
capable of being pushed forward and made to pass the stricture. 
The operation is made in the following manner : The catheter, 
with the director concealed within it, is passed down the ure- 
thra until its point reaches the- obstruction, when, by a dexter- 
ous manipulation, the director is passed through the stricture, 
and on into the bladder ; the surgeon then takes a very small, 
sharp-pointed tenotome, and feeling in perineo for the buttons 
or knobs, plunges the knife between them in the groove, and 
then along the groove in the director through the "stricture, 
which is freely incised ; the edge of the knife being directed 
downwards. After the stricture has been freely cut, the 
director is withdrawn into the catheter, which is now removed 
from the urethra, and a full-sized catheter carried on into the 
bladder. The little wound is covered with a bit of sticking 
plaster, a compress, and a T bandage completes the dressing. 
No retained sound is left in the bladder, but whenever there are 
calls to urinate, the water is drawn off with a catheter. 

This is certainly a very unique and ingenious operation, and 
one which strikes at the chief point of objection, to all external 



20 

operations — viz., an open wound in the perineum, which, in 
general cases, must heal by granulation ; but there are objec- 
tions to Mr. Dick's operation which will prevent it from coming 
into universal use. In the first place, it is a difficult one to per- 
form, and requires a degree of dexterity which does not belong 
to the Profession at large ; then we have no absolute certainty 
that the director has passed into the stricture; it may have pen- 
etrated a false route, and the incision made subcutaneously, in 
that event, may be productive. of serious consequences. Then 
again, he holds it as a necessity, that the stricture "must, to a 
small extent, first be dilated." This is required before his con- 
ducting director can be introduced. Now, if it is requisite first 
to dilate the stricture so as to admit the guide for the tenotome, 
I hold, upon the same grounds, that the objection was made to 
Mr. Syme's operation ; there is no necessity for an external 
incision. In this, as in every other case where a guide can first 
be passed, we can perform the gentler, the safer, and more 
rational operation of internal urethrotomy. External sections 
are, without doubt, only required in those cases where we are 
unable to introduce any instrument through the stricture. 

I now come to the description of the operation which has 
been adopted by myself, and which, so far, has proved satisfac- 
tory to me and to those upon whom it has been performed. The 
operation itself is nothing more than the old l'boutonniere, in 
which the incision is made anterior to the stricture, a probe 
passed through the obstruction, and the stricture cut subcutane- 
ously, and the wound healed by first intention. It is only re- 
sorted to in those cases of impermeable or impassable stricture, 
where no catheter or guide can be made to pass from the meatus 
to the bladder; cases which require some operation for the im- 
mediate evacuation of the retained urine. I claim as new only 
the method of incising the stricture, and the process resorted to 
to gain immediate union. 

Having duly prepared the patient by cleaning out his bowels 
with an enema, and a warm hip-bath given to tranquilize his 
condition, he is placed upon a table and firmly secured in the 



21 

position for lithotomy. Being under the influence of chloro- 
form, a staff sufficiently large to fill the urethra and moderately 
curved at the lower end is passed down to the face of the stric- 
ture, and confided to the care of an assistant, who is instructed 
to elevate the testicles, and keep the point of the staff firmly 
against the stricture, holding it in such a manner as to protrude 
the perineum with its point; now, with a sharp-pointed convex 
scalpel, an incision is made in the line of the raphe, through the 
integuments down to the outer walls of the urethra, which is 
then opened upon the groove in the point of the staff. The in- 
cision in and through the integuments should be free and about 
one and a half to two inches in length ; the opening in the urethra 
is less, being from one-half to three-quarters of an inch, and stop- 
ping at the superior face of the stricture. The edges of the 
wound in the urethra are now to be held apart by a silk thread, 
which is passed through its urethral margin by means of a very 
delicate curved needle, and the threads, one on either side, are 
entrusted to the care of the two assistants, who are supporting 
the patient's knees (the method suggested and adopted first by 
Mr. Avery, of London). The staff-holder is now instructed to 
remove tire staff. Through the incision made in the urethra a 
small probe is passed, either of whalebone or silver, and the 
opening into the stricture searched for. To enter this is not 
always an easy matter, but by care and patience, the probe can 
be gently insinuated into the smallest orifice, and through the 
closest stricture, where urine can find its way ; being down upon 
the face of the obstruction, it is a much easier matter to intro- 
duce the probe than if it were passed from the meatus through 
the length of the canal. No force should be used, for it is very 
easy to create a false passage, and thus greatly complicate the 
success of the proceeding. After the probe has penetrated 
through the stricture, a second probe should be worked in 
alongside of the first, and on into the bladder; now, by gently 
pressing in first one and then the other, and separating them 
from each other, so as to stretch open the mouth of the stric- 
ture, it will be found to open sufficiently large to admit the in- 



22 

traduction of a small grooved probe, or a narrow probe-pointed 
tenotome, with a long shank, between the bristle probes. Hav- 
ing now gained an entrance for the knife, we have only to make 
an incision in the median line, with the edge of the knife 
directed downwards, and the stricture is cut; this must be done 
freely, so that no bands or fibres be left ; the blade must pass 
through the mucous membrane into and through the submucus 
layer, even to but not through the fibrous element of the ure- 
thra. 

We thus perform, as it were, an internal section of the stric- 
ture; we do not rip open the whole coarctated urethra and lay 
bare to the external wound the cavity of the canal where the 
stricture has been, but we leave the urethra, so far as the stric- 
tured part is concerned, just in the same condition as an ure- 
thra upon which we had performed an operation by internal 
urethrotomy. The opening down to and into the urethra is an- 
terior to the face of the obstruction ; it simply serves us the 
purpose, as it were, of shortening the canal, and placing it in 
the condition of a female urethra ; it thus permits us to get 
near the seat of the disease, furnishing a passage of only a few 
lines in extent, in which to manipulate our instruments, instead 
of a canal of several inches in length, as would be the case if 
the urethra had not been cut open. 

Having incised the stricture free enough to pass in a sound, 
we now introduce a full size gum catheter, draw off the urine, 
withdraw the catheter, and then gradually enlarge the calibre 
of the canal by the passage of metal sounds, until the urethra 
has reached its maximum point of dilatation possible. Having 
done this, we wash out the wound with clean, cold water, so as to 
clear it of any drops of urine which may possibly have entered 
it in the withdrawal of the catheter. After all appearance of 
any oozing of blood has ceased, we then place in the bladder, 
through the urethra, a full sized gum catheter, and proceed to 
close the wound accurately. For this purpose we employ the 
ordinary suture pins, of which we pass two, three, or four, as 
the length of the external wound may call for, entering them 



23 

about half an inch from the free margin of the wound in the in- 
teguments, and passing them deeply, almost to the urethra, and 
bringing them out on the opposite side, at the same distance 
from the edge of the incision to which they had been entered 
on the other side. The edges of the wound are now evenly and 
smoothly coaptated, whilst the intervals between the deep-seated 
pins are more securely closed by the introduction of smaller 
pins, which are passed less deeply— simply through the skin 
proper. The pins are now encircled by a firm, flat silk ligature 
running from one to the other, in the form of united figures of- 
8 ; we thus insure both superficial and deep pressure upon the 
sides of divided tissue. The catheter is left open in the ure- 
thra to drain off the urine as it is collected in the bladder. The 
patient is kept on his side in bed, with a pillow between the 
knees, and a urinal unaer the lip of the catheter to catch the 
urine as it escapes. The wound is kept constantly saturated 
with a mixture of cold water and the tincture of arnica, ap- 
plied by means of soft cloths. 

At the expiration of twenty-four to thirty-six hours the ca- 
theter is removed, and a new one substituted. In about two or 
three days the catheter is dispensed with, and only used when 
calls are made to micturate. On the fourth, fifth, or sixth day, 
as their appearance may indicate, the deep pins are removed, 
and as the perineum regains its shape and appearance, the su- 
perficial pins are one by one taken away. 

Within a week we begin with a small size Benique sound, 
and gradually, every other day, increase the size of the instru- 
ments until the urethra reaches the size of its natural calibre. 

Immediately after the operation we give from fifteen to 
wenty grains of quinine with, forty drops of the elixir of 
opium, and for a day or two keep up a moderate impression 
with quinine and the tincture of chloride of iron. The latter 
being administered in ten to fifteen-drop doses three times per 
day, and continued for a week or ten days. "We are careful to 
drain off the urine each time there is a call to relieve the blad- 
er, until the wound has entirely healed, or so long as any ten- 



24 

derness exists about the seat of the stricture. "With this course 
judiciously pursued, we can in the large majority of cases dis- 
charge our patient perfectly healed, and entirely cured, in from 
twelve to fourteen days. Upon his discharge he must be fur- 
nished with a metal sound and instructed as to its use, which 
he must continue for ah indefinite length of time ; unless he 
does the stricture will, as after all operations, close up again. 

Now, what are the advantages to be derived from such a 
course ? The main point is to hasten the healing of the wound 
in the urethra, and by the use of the pin suture, we place the 
parts in such perfect apposition that they must heal ; we thus 
shorten the duration of time required for the patient to be 
kept confined, and, by gaming union by the first intention, we 
lessen the amount of cicatricial tissue which is always depos- 
ited in greater proportioD, the longer the healing process con- 
tinues. We believe there is less danger of secondary haemor- 
rhage after cases which are treated in this way than in any other. 
In resorting to the retained catheter for the first day or so, we 
are convinced that we lessen the risk of any haemorrhage, as it 
acts at the onset by pressure upon the divided stricture; com- 
presses the vessels which have been divided and which may 
bleed after reaction ; it keeps open the urethra and prevents 
the stricture from again uniting in a very short time, as it is 
prone to do, as shown in those cases of internal section where 
no in-lying catheter has been kept. 

For a day or so the presence of the catheter can do no harm, 
whilst it certainly does accomplish much good ; it keeps the 
urine from the cut surface until it has glazed over with lymph, 
and, by its mechanical action upon the urethra, keeps it en- 
larged to such a point that when we begin to use the metallic 
sound for the purpose of dilating the urethra to its maximum 
point of distension possible, we will not find any obstruction in 
the way. I believe that this in-lying catheter has a powerful 
controlling influence towards preventing rigors and urethral 
fever, and upon these grounds : By the use of the catheter the 
urine does not at first come in contact with a raw surface, and 



25 

hence does not irritate the wound ; after the second clay the 
urine begins to find its way along the sides of the catheter, 
and then may do, as it will, injury; but at this date we remove 
the catheter, and only employ it whenever there are calls to 
urinate ; we thus prevent any contact of urine with the wound. 
I am convinced that rigors are generally produced by the con- 
tact of the urine with the urethra, immediately after the intro- 
duction of a sound; for in those cases where I have guarded 
this point, by the use of the catheter, I have not had rigors to 
follow as a sequence of operations; and, as a proof of this fact, 
rigors do not generally come on after operations until the pa- 
tient has urinated. This fact had engaged my attention some 
time since, and recently I have seen that mention has been 
made of it by Mr. Paget in his clinical lecture upon the treat- 
ment of stricture, published in the " British Medical Journal," 
April 2, 1870. 

Another point of interest is, the climatic influences which 
govern the healing of wounds, and to which fact I may owe 
much of my success in gaining union by the first intention after 
external sections. It is well known by every one who has prac- 
ticed medicine and surgery in and around Mobile, that wounds 
of all sorts heal more speedily here than in any other locality 
of the South ; it not being an infrequent occurrence to gain pri- 
mary union after the most extensive operations. I have had 
on one occasion the stump of an amputated thigh to heal by 
first intention, and have frequently seen amputations of less 
magnitude behave in the same way. I mention this to show 
what influence climate may have had upon the cases which I 
will now record. 

Case I. — H. B., aged twenty-seven, August, 1S68, has had 
stricture located in the first region, at the junction of bulb 
with ■ membranous portion for several years ; two fistules of 
small size in perineum. The stricture very tight and firm. 
Operated upon him by opening the urethra in advance of the 
stricture and then incising it subcutaneously. The fistules 
were split and cauterized. The wound made into urethra 



26 

closed with pin sutures, and a retained catheter left in urethra. 
In some six days the wound had perfectly healed, and the ure- 
thra admitted with ease a 46 Benique sound. The urine had 
ceased to pass by the sinuses leading from the urethra, and 
they were healing kindly by granulations. I have been unable 
to keep up the history of the case, as my patient left the city 
apparently well. 

Case II. — F. B., a gentleman of this city, aged fifty-nine, 
had been troubled with stricture since he was nineteen years of 
age ; near forty years. He first consulted me in the spring of 
1868, having been under the care of a number of physicians, 
both regular and irregular. His urethra was riddled by false 
routes, one of which left the urethra in front of the bulb and 
entered the rectum. I have several times passed a No. 5 gum 
bougie through the urethra and brought it out at the rectum. 
And it was not an unusual occurrence when his bowels were in 
a lax condition for him to pass his faeces in small quantities 
mixed with urine via the urethra. Having tried in vain to get 
an instrument into the bladder so that I could perform an in- 
ternal section, I informed him that I knew of no method by 
which I could hope to render him any relief, save by the opera- 
tion done externally. To this he could not gain his assent; 
and determined to try to worry along as he had done for years. 
But during the winter and spring of 1869 he rapidly grew 
worse, his stricture was so far closed that he could pass his 
urine only in drops. Being unable to sleep, having to get in 
and out of bed from fifteen to twenty times during the night, 
his clothes saturated all the time from the constant overflow of 
urine ; and his health fast failing from urssmic saturation, he 
made up his mind to submit to anything in the range of surgi- 
cal art for relief; consequently the 26th of May, 1869, was 
selected as the day upon which he would submit to the operation 
proposed. Without prolonging the description by giving the 
steps of the operation, which was done after the manner previ- 
ously given, I will simply state that on the 29th of May, four 
days after the operation, the pins were all removed, the wound, 



27 

which was made in the first region, and in extent two inches, 
directly in the median line of the perineum, had healed per- 
fectly by the first intention, and with the exception of the little 
red points where the pins had been passed, and the line through 
which the incision had been made, there was no evidence of any 
operation ever having been performed. His urethra received 
with ease a No. 52 Benique sound, and being instructed to pass 
a steel sound of this size once in two weeks for an indefinite 
length of time, he was discharged on the third day of June, 
just seven days from the day upon which the operation was 
done. Some six months after the operation I made a careful 
examination of his urethra with the ball bougie, and was un- 
able to detect any remains of the stricture ; the false routes 
had entirely healed; and for two years thereafter he enjoyed 
uninterrupted health; at which time he was taken with an 
attack of acute inflammation of the stomach and liver, from 
which he died. 

Case III. — V. B., a gentleman aged forty-five, had been 
suffering for some twelve years from a stricture located near 
the lower margin of the fossa navicularis. I was called to see 
him on the 22d August, 1870 ; he had complete retention of 
urine, and was in a partial comatose condition ; the stricture 
was at least half an inch in length, and so dense that it could 
be easily felt and examined through the urethra. I at once 
determined to lay the urethra freely open, and to close it with 
the pin suture, which was done by passing down to the face of 
the stricture a female sound, upon the end of which I cut down, 
and then continued my incision freely through the stricture. 
Placing in a No. 12 gum catheter, I drew off the urine, and 
closed the wound by passing two silver pins and encircling them 
with a silk thread in the form of a figure 8. On the 31st of 
the month, nine days from the date of operation, I discharged 
him perfectly well, the wound having healed by first intention. 
To this date, September, 1872, he has had no trouble from the 
stricture, and is not likely to have, as he is persistent in the 
use of his steel sound. 



28 

Case IV. — J. M., aged twenty-seven, called on me 21st of 
January, 1871, to examine him for a stricture located at the 
bulba junction with the membranous urethra. An abscess ex- 
isted at the time exterior to the urethra, which I opened. 
Afterwards incised the stricture in the perineum, and closed it 
with pin sutures. The wound healed kindly, and the stricture 
was cured, and now remains patent to a 52 Benique sound. He 
uses a No. 15 English steel sound, and has no trouble. There 
is, however, a disposition to the formation of abscesses around 
the ischio-perineal fossa, which, when opened, discharged a 
small quantity of pus and then rapidly disappeared. There is, 
evidently, a connection between them and the urethra ; but as 
they give so little trouble he is satisfied to get along without 
further surgical interference. 

Case V. — B. W., colored, fifty-two years of age, was placed 
under my care in the summer of 1868, suffering from com- 
plete retention of urine, dependent upon two strictures. A 
slight stricture in the second region, and a hard, firm stricture 
at the junction of the first and second regions. When I first 
saw him he was comatose, and had been so some hours. I was 
then unable to get any history of his case. Finding it impos- 
sible to pass an instrument, I determined to cut through the 
first stricture, as it was a very slight one, with an urethrotome, 
in the axis of the urethra, which procedure let me down to 
the second stricture; for the relief of which I operated by the 
method (I have described) of external section ; making my in- 
cision in the urethra anterior to the scrotum, which I closed by 
pin sutures, used a retained catheter, and gained union by 
first intention. I examined him last in December, 1870, and 
with ease introduced a No. 45 Benique sound. These are the 
main facts in this case, but as I did not keep close notes of the 
treatment, it is not in my power to give them more in detail. 
The chief point of interest in this case is the immediate union 
which took place, of an incision which was made into the 
urethra, just anterior to the scrotum, a locality where it is very 
difficult to close up urethral openings. 



29 

Case VI. — P. D., a youth of fifteen years of age, was brought 
to Mobile and placed under my care for treatment of an injury 
of the urethra and perineum. As the case is one of peculia 
interest, I have thought proper to give the history of the acci- 
dent, together with the course of treatment pursued, with its 
results. The facts are as follows: On the 7th day of March, 
1867, this little boy was engaged in walking along the line of a 
plank fence ; tripping his foot, he fell astride of a plank, bruis- 
ing his perineum in a most terrible manner. Great swelling 
ensued, with total retention of urine, which lasted from that 
day until the night of the 10th instant, at which time a physi- 
cian succeeded in passing a catheter, and drew off the urine. 
All this while he had remained in a state of absolute stupor. 
From that day his urine was drawn regularly for the succeed- 
ing eight days, when an abscess pointed and discharged a quan- 
tity of pus, mixed with urine. After which, for the next two 
months, a catheter was kept in the bladder until the opening of 
the fistule was thought to have healed, which was not the case, 
as, upon the removal of the catheter, the urine flowed as before 
through the fistule. " An operation " was now done, by laying 
open the sinus and then closing it with sutures, and a catheter 
retained for the succeeding eight days. After which, the ca- 
theter was removed, when the fistule again opened, with slough- 
ing of the adjacent parts, and the urine ceased altogether to 
pass through the urethra. In this condition he continued to 
drag out a miserable existence for thirteen months, when he 
was brought to Mobile for treatment. He was placed under 
my care on the 14th of September, 1869. An examination 
revealed the fact that the urethra was closed completely at four 
and a half inches from the meatus. The perineum was sunken 
in, showing the ravages of extensive sloughing. A small fis- 
tule existed near the margin of the anus, through which his 
urine was voided in a strong, bold stream ; in a word, his ure- 
thra was a "cul-de-sac " of four and a half inches in depth, at 
which point it ceased, and there was no evidence of any contin- 
uation or even remains of an urethra from that point toward 



30 

the bladder. In truth, the entire membranous, with a portion 
of the bulba urethra, seemed to have sloughed away. The 
course of treatment was soon decided upon, and with but 
faint hopes of success. I proposed the following operation, 
which was accordingly done. Properly prepared and secured 
in the position of lithotomy, a staff was introduced into the 
urethra, and down to the cul-de-sac, which was opened upon the 
point of the instrument; an incision was now made from the 
extremity of this opening, in the line of the raphe, to within 
half an inch of the anus, through the integuments, and the re- 
mains of the urethra sought for. Being unable to find any- 
thing else than a mass of cicatricial tissue where the urethra 
once was, I passed a probe through the sinus from the mouth of 
the fistule and on into the bladder. Connecting this sinus with 
a bold incision through the perineum, I now placed a No. 8 
gum catheter through the urethra, laying it along the incision 
in the perineum, and thence on through the sinus into the blad- 
der. The urine now passed boldly along the catheter. ft 
remained only to bridge over the catheter in the perineum, 
which was easily done by turning over the flaps from either 
side and uniting them with pin sutures, and the operation was 
finished. The case progressed very well for four or five days, 
and the wound, in a measure, had healed, when he was seized with 
an attach of bilious fever, which lasted some two weeks, and 
from which he barely escaped with his life. Yet, notwithstand- 
ing this, the urethra was kept open by the introduction of the 
catheter whenever nature required to be relieved, and although 
one or two small fistules opened along the track of the incision, 
he nevertheless had the assurance that a canal existed from the 
bladder to the meatus of the penis. In this condition it be- 
came necessary that he should be sent to the country for a 
change of climate, it then being in the midst of our sickly sea- 
son. His father was instructed in the use of the catheter, and 
advised to use it, night or day, as he had calls to urinate. He 
left Mobile in the early part of October, and I saw nothing 
more of him until the 27th of December following, when he 



31 

returned to the city. His father had regularly used the cathe- 
ter as advised ; and, upon examination, I found that a No. 38 
Beneque sound passed with great ease along the urethra ; that 
only one small fistule remained, into which I could scarcely in- 
troduce an Anel probe. The ball probe detached a rough, val- 
vular point in the new-made urethra, which I incised with a 
retrograde urethrotome of Civiale, and having furnished him 
two steel sounds, Nos. 11 and 12, English scale, he left for 
home, with instructions to use the sounds at regular intervals 
of a week for an indefinite time, and to continue to draw oil 
the urine with the catheter until the fistule was entirely healed, 
with what result the following extract from a letter recently re- 
ceived will fully explain : 

"June 10th, 1872, Alabama. 

* * * * "P continues perfectly well ; his 

urine has continued to pass without the least obstruction 
through the natural channel since the day of your first opera- 
tion. ^The little fistule healed very soon after he left Mobile. 
The only means used to obtain this desirable end (a final and 
perfect cure) was the introduction of the bougie, as you directed, 
once or twice a week, after he came home; and through cour- 
tesy to you, he has continued to use it once in two weeks ever 
since, though he says he is perfectly relieved, and as well as he 

ever was in his life. * 

11 1 am truly your friend, J- D. ^.' 

This was a most interesting case, and one which certainly 
goes to prove the very great value of such operations. Although 
not simply a case of external urethrotomy— for it was even 
more than this— it shows the possibility of making extensive 
operations in the urethra, and gaining immediate union there- 
after. 

Case VII.— E. M. Q., a West Indian, aged thirty-eight, ha?, 
since he was nine years old, had trouble in passing his urine. 
Whilst a youth, had frequent attacks of retention. It was 
thought that he had been injured upon the pommel of a saddle. 



32 

After corning to the States, lie had other trouble with his ure- 
thra, and was forced for years to introduce a catheter to enable 
him to pass his urine. In 1868, (September 18,) he came to 
me for treatment. An examination revealed a considerable de- 
viation of the urethra, with a stricture in first region at bulba 
and membranous junction, through which, with difficulty, I 
passed a No. 2 English conical bougie. After fruitless en- 
deavors to dilate the stricture, I freely incised it with an in- 
ternal urethrotome. After which he was furnished with steel 
sounds to No. 45, Benique scale, and advised to use them. This 
he ceased to continue after the expiration of a month, as he 
" thought the stricture was well." The result was, the stricture 
gradually, slowly, but surely, closed up again. In the spring 
of 1871, it had contracted to a No. 5 English bougie, and he 
had difficulty in passing his urine. He tied in a catheter for 
six to eight hours each day, and got about as usual; but owing 
to neglect, his stricture had so far closed, that on the 22d of 
June, 1872, he was forced to place himself again under my 
care, with almost perfect and complete retention. After several 
hour's trial — with all the adjuvants— I was enabled to get into 
his bladder a whalebone probe of one-third of a millimetre in 
diameter, by Charriere's scale. On the next day he passed 
about a g^ill of urine. It being utterly impossible to effect any- 
thing by internal section, I proposed to perform my operation 
of external section. To this he objected ; but as complete re- 
tention followed on the 24th, he sent for me, and requested that 
the operation should at once be performed. Calling in Drs. 
Hamilton, Gelzer, Iglehart, and Wm. Mastin, medical student, 
to aid me, I proceeded to perform the same operation which has 
been before described. Without consuming space or time with 
the details of treatment, as kept in my case-books, I will, in 
closing this report, say : The operation was performed on the 
24th of June. The catheter was removed on the 26th. The 
pins were taken out on the 1st of July. On the 3d of the same 
month the pin-holes were closed up entirely ; perineum per- 
fectly smooth, showing only a red line along the raphe, and the 



case discharged ; having furnished him with a steel sound of 
No. 54 calibre, Benique scale. On the 24th of June he had, 
at 11 o'clock A. M., retention of urine. On the 3d of July, at 
same hour, just nine days thereafter, he was passing a No. 54 
sound, having undergone the operation of external section, and 
been discharged perfectly cured and the wound soundly heeded. 
Case VIII. — M. R., aged thirty-two, a laboring man, was 
placed under my care, suffering with stricture, 1st of August 
1872. He had suffered on various occasions for ten or twelve 
years past with retention ; had been treated in Havana, where 
some operation had been done upon him, which he was unable 
to describe. His constitution was very much impaired, show- 
ing evident marks of syphilitic taint. The stricture located at 
the bulb was very hard and firm. With much difficulty I 
passed a whalebone probe one-third of millimetre. There was 
also a close stricture at the meatus. Having determined to 
operate by external section, I advised, after the suggestions of 
Dr. Gouley, a course of preparatory treatment, which, however, 
he was unable to continue for any length of time. As com- 
plete retention decided me on the morning of the 3d of August 
to perform the operation without further delay, so, assisted by 
Drs. Crampton (who had placed the case in my hands) Hamil- 
ton, Henderson, and in the presence of several other medical 
friends, I did the operation which is usual with me in these 
cases. Finding it to be necessary to open the mouth of the 
urethra so that a sound would pass to the stricture proper, it 
was accordingly done by Civiale's meatatome, when, owing to 
the excessive haemorrhage, the operation was delayed for half 
an hour, until the haemorrhage ceased. This showed the haem- 
orrhagic diathesis under which my patient labored, and I 
feared trouble when I should come to incise the bulba region of 
his urethra ; yet I proceeded to perform the same operation 
that I had done in the other cases. Having opened both the 
urethra and stricture, I drew off some eighteen ounces of urine, 
but was unable to dress the wound, owing to the haemorrhage 
which ensued. No vessel was cut, but the blood oozed fast 
3 



34 

from the divided edges of the urethra, so much so that I was 
forced to delay the dressing for over an hour and a half, at 
which time, as in the other cases, I closed the wound over a re- 
tained catheter, using the pin suture. A No. 54 Benique 
sound passed with ease. He was placed upon the usual course 
of after-treatment, and continued to get along very well. That 
night he let the catheter slide out of his urethra, and it was 
not replaced until the next day. The next night he again 
either let it slip out or intentionally removed it, and passed his 
urine at pleasure through the urethra, soon after which he was 
taken with a rigor, followed by fever, which lasted until the 
next day — viz., 5th instant. Finding that he proved a rebel- 
lious patient, and disregarded advice and instructions, I deter- 
mined to let him go on and see what would be the end of the 
case. All hopes were lost as to the success of gaining union 
by first intention. In attempting to pass a sound, there was 
considerable discharge of blood, and we concluded to let him 
rest without any interference, as he was passing his urine in a 
full stream, and the wound continued to look well. No change 
in his condition since the 6th instant, the pins seemed to re- 
main as when introduced, when on the 15th I removed the 
pins, having left them in a very much longer time than is my 
habit; but as they seemed to be just as they were when intro- 
duced, I saw no necessity to make any change, and left them 
more for a support than any other reason. After the removal 
of the pins a small opening remained at one point of the en- 
trance, from which some pus in very small quantities passed. 
The wound is healed in its entire length, and now twelve days 
since the operation the result shows perfect success. 

There was some spasm of the urethra upon the passage of a 
sound, which necessitated that it should be touched with nitrate 
of silver on two occasions, so as to reduce the irritability, and 
permit the bougie to enter the bladder, which it now does, No. 
48 Benique sound passing without obstruction. 

In spite of the syphilitic taint and the hemorrhagic diathe- 
sis of my patient, coupled with his unmanageable disposition, 



35 

the results of this case are most satisfactory and remarkable. 
In twelve days from the time of my operation my patient was 
relieved of his stricture, the wound in the perineum healed, 
and he ready to be discharged. 

Such is but an outline of these cases ; each one was a severe 
case, and in each I have had most unusual and remarkable suc- 
cess. It would have been interesting to have given day by day 
the notes of them as recorded in my case-book, but it would 
have only consumed time and space to have done so. The main 
essential points have been given with sufficient accuracy to show 
the operation was done, with its results. Another case, which 
would make the ninth in my list, I have unfortunately lost the 
notes of, and hence do not include it here. 

I am not aware that like results have ever before been met 
with of such rapid recovery after such operations, and hence I 
give the outlines of the cases. 

In this connection it may be well to say a word of caution 
in reference to the injurious effects which may result from all 
operations upon the male urethra, it matters not what method 
is adopted, or how trivial the interference may have been. 

It is well known that the urethra is one of the most, if not 
the most delicate organ in the body, especially so in those nerv- 
ous, debilitated subjects, the victims of long-standing urethral 
disease; here we find a class of patients peculiarly prone to 
great nervous shock; and who are easily affected by the most 
trivial operations done upon the genito-urinary system. It is 
not an unusual result after these operations that we find the 
gravest symptoms arise. I allude to the occurrence of active 
inflammation of the articulations, followed by the formation of 
pus in the joints, muscles, veins, cellular tissue and other struc- 
tures. The symptoms which usher in these cases are so marked 
that the well-informed surgeon cannot fail to observe, and 
in the majority of cases should be enabled to meet and over- 
come them by judicious and properly executed treatment; a 
detail of which would be out of place in an article of this na- 
ture, as it is presumed that every one who is called upon to un- 



36 

dertake such operations will be at least so informed upon the 
subject that he will be at no loss to meet the complications 
which may arise; that he will at once recognize the indications 
as they present themselves, and to know by what course of 
treatment they are to be met and combatted. 

There are, however, a class of persons of such delicate and 
impaired constitutions that even without the least warning 
given, may sink and die after the most trivial operation upon 
the urethra. The recorded case of a patient, in the hands of 
M. Velpeau, dying from tetanus the day after the introduction 
of a bougie, and upon whom an autopsy was at once made, and 
no signs whatever of any lesion being found, shows how trivial 
the cause may be which produces fatal results. 

In my own limited observation, I now call to mind a case 
which I witnessed of a like fatal termination. A young -man, 
sick of an ordinary case of remittent fever, was suffering from 
retention of urine. The physician in attendance (now dead), 
one of the most able and accomplished practitioners who ever 
resided in this section of the South, cautiously introduced a 
No. 8 silver catheter with the intention of drawing off his 
urine. There was no stricture, and no apparent disease of the 
genito-urinary system ; but before the catheter had reached the 
bladder, the man was seized with a serious convulsion, and life 
was extinct in less time than I have consumed in writing this 
paragraph. An autopsy was made, but the cause was hidden 
in some portion of the sympathetic system, where we were una- 
ble to find it. 

These facts are thus briefly noticed to draw the attention of 
the general practitioner to the dangers which may arise in this 
class of operations, and to suggest the necessity of prudence 
and preparation before such are undertaken. They are not 
given to discountenance proper and judicious surgical interfer- 
ence; for all operations are more or less dangerous. No one 
can predict the termination of the simplest, or say with cer- 
tainty that the most serious will or will not prove fatal. One 
man has died from the sting of a bee, or the scratch of an oys- 



37 

ter-shell ; another more fortunate has withstood the shock of a 
coxo-femeral disarticulation, or the operation of lithotomy. 
Who can then say that this or that man will or will not survive 
the slightest or the most serious operations upon the genito- 
urinary apparatus? 

The urgency of the symptoms and the condition of the pa- 
tient at the time are alike the indications which dictate the pro- 
ceeding we are called upon to adopt in each particular case ; 
for it is to avert more certain dangers that we are justified in 
calling into requisition the aid of the surgical art ; and we are, 
upon this basis, supported and required to extend to our patient 
all the chances of relief. 

Yet, notwithstanding there are strictures of the urethra 
which, from their obstinacy and duration, together with the 
serious constitutional troubles which they are producing, as for 
example, cystitis, hypertrophy of the walls of the bladder, dil- 
atation of the ureters, with disorganization of the kidney 
itself, which require so grave a proceeding for their relief as 
external urethrotomy; we should not consider them of frequent 
or general occurrence. In proportion to the large number of 
strictures which apply to us for relief, such cases are compara- 
tively rare ; and even then, as a general rule, the operation of 
external section should not be resorted to until all other modes 
of rational treatment had been expended. 

Hence, I feel safe in saying we will find the very large ma- 
jority of strictures yield to some one of the milder methods, 
among which dilatation stands preeminent; and we are not far 
from correct when we advocate dilatation first. Dilatation 
always, although there are many strictures which are so very 
irritable that they will not tolerate the use of the bougie until 
the irritation has been, in a measure, subdued by the use of the 
milder caustics. Next to this, when a case has proved rebel- 
lious to the dilating power and cannot be overcome, then the 
operation of internal urethrotomy is peculiarly applicable, pro- 
vided, as a necessity, that a guide-rod can first be introduced 
•past the coarctation ; here we will surely accomplish a much 



X 



38 

safer proceeding than can be done by any other method. 

As to divulsion — on general principles I am opposed to it, 
and in those cases where milder methods have failed, would 
always give the preference to external urethrotomy. And in 
the selection of the form of the operation, for reasons given, I 
will prefer the one which I have above described. 

In offering the results of my own experience with this method 
in the treatment of strictures after external sections, I do so 
for the purpose of bringing it before the Profession, with the 
hope that more able investigators will test its merits, as well as 
the objections which may be brought to bear against it. 

The statements which I have made are rigidly truthful. So 
far, I have had nothing but success ; and I now lay the matter 
before the Profession, so that it can be tested on a larger scale. 
If, after a more extended investigation, this treatment should 
not hold good in practice, I will very willingly abandon it for a 
better, whenever such can be found ; it matters not whether it 
be a creation of my own, or shall emanate from a more worthy 
source. And now, in conclusion, I am candid when I say, if 
the method which I have advocated should fail, I will most 
willingly be the first to announce it. 

All I ask from the Profession is a fair trial before it is con- 
demned. " Valeat quantum valere potest." 

ADDENDUM. 

Since the foregoing article went to press, the following case 
has fallen under treatment, and I here give a brief outline of 
it: 

J. K., (colored), aged about fifty years, was placed in my 
charge January 14th, 1873. -I found the urethra impervious ■$©► *^r 
the bulb ; five fistules involving the scrotum and the nates. 
His history was that he had labored under stricture for three 
years; that twenty months previous to this date he had been 
cut internally, but very little good resulted, as the fistules re- 
fused to heal, and in a short time the urine ceased to pass via 
the natural canal. Again, twelve months ago another opera- 



39 

lion for internal urethrotomy afforded no better results. I con- 
cluded upon the " external section" and on the 16th day of 
January, operated after my method, and united the wound with 
two silver sutures, and retained a catheter thirty- six hours. 
The operation was a difficult one, as the perineum was very 
deep, and the deposit of cicatricial tissue very dense, the ure- 
thra also ending near the bulb in a " cid-dc-sac." Under the 
usual course of treatment adopted in these cases, the wound 
healed by the first intention. The urethra is open to No. 46 
Benique scale, and the fistules are healing kindly. His water 
is drawn regularly by an attendant with a catheter, and the 
probability is, the cure is a complete and radical one. 



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